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Strokes in young adults: epidemiology


and prevention

This article was published in the following Dove Press journal:


Vascular Health and Risk Management
24 February 2015
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Devdet Smajlovi Abstract: Strokes in young adults are reported as being uncommon, comprising 10%15% of
Department of Neurology, University all stroke patients. However, compared with stroke in older adults, stroke in the young has a dis-
Clinical Centre Tuzla, School of proportionately large economic impact by leaving victims disabled before their most productive
Medicine, University of Tuzla, Bosnia years. Recent publications report an increased incidence of stroke in young adults. This is impor-
and Herzegovina
tant given the fact that younger stroke patients have a clearly increased risk of death compared
with the general population. The prevalence of standard modifiable vascular risk factors in young
stroke patients is different from that in older patients. Modifiable risk factors for stroke, such as
dyslipidemia, smoking, and hypertension, are highly prevalent in the young stroke population,
with no significant difference in geographic, climatic, nutritional, lifestyle, or genetic diversity.
The list of potential stroke etiologies among young adults is extensive. Strokes of undetermined
and of other determined etiology are the most common types among young patients according
to TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria. Prevention is the primary
treatment strategy aimed at reducing morbidity and mortality related to stroke. Therefore, primary
prevention is very important with regard to stroke in young adults, and aggressive treatment of
risk factors for stroke, such as hypertension, smoking, and dyslipidemia, is essential. The best
form of secondary stroke prevention is directed toward stroke etiology as well as treatment of
additional risk factors. However, there is a lack of specific recommendations and guidelines for
stroke management in young adults. In conclusion, strokes in young adults are a major public
health problem and further research, with standardized methodology, is needed in order to give
us more precise epidemiologic data. Given the increasing incidence of stroke in the young, there
is an objective need for more research in order to reduce this burden.
Keywords: cerebrovascular diseases, age, incidence, risk factors, etiology, management

Introduction
Despite considerable improvement in primary prevention, diagnostic workup, and treat-
ment, stroke is in second or third place on a mortality list, and projections indicate that
it will remain so in the year 2020. Furthermore, stroke is a leading cause of disability.
Although published reports indicate that stroke is not common in young adults, in
everyday clinical practice we are often faced with acute neurologic symptoms in this
age group, and stroke should be considered as the differential diagnosis. The nature
and etiology of stroke in young adults is different from that in older patients, and
Correspondence: Devdet Smajlovi has an influence on diagnostic evaluation and treatment, so knowledge gleaned from
Department of Neurology, University research in older patients cannot always be applied to young adults. Compared with
Clinical Centre Tuzla, Trnovac bb,
75 000 Tuzla, Bosnia and Herzegovina
stroke in older people, stroke in the young has a disproportionately large economic
Email dzsmajlovic@hotmail.com impact by leaving victims disabled during their most productive years. Of concern are

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data indicating an increasing incidence of stroke in younger The estimated annual occurrence was 10.8 (range 8.4 to 13.0)
age groups.1 per 100,000, increasing exponentially with advancing age.
When discussing the epidemiology of stroke, first we need Groppo etal reported a crude incidence of stroke of 12.1 cases
to understand what is meant by a young patient. To define per 100,000 among young Italians.8
an age cut-off is challenging and sometimes arbitrary, but Racial and ethnic differences in risk of stroke are widely
previously published studies and registries commonly define recognized, and these differences are even greater in younger
young adults as those younger than 45 or 49 years. This paper populations. The racial composition of a study population
provides an overview of the epidemiology and prevention of is an important component of incidence variability. The
strokes in young adults. It is based on a review of population- Northern Manhattan Study showed that young blacks and
based, community-based, and hospital-based studies of stroke Hispanics have a greater incidence of stroke than young
in young adults, with a focus on papers published within the whites.9 In another study in Florida, young black adults and
last 10 years. Data used in this review were identified by a Hispanics had a significantly higher hospitalization rate for
MEDLINE search using the search terms stroke and young stroke than whites.10 A high stroke incidence (70/100,000)
adults, ischemic stroke and young adults, hemorrhagic in the 3544 year old age group has also been observed in
stroke and young adults, epidemiology and young stroke, Japan,11 as well as among young and middle-aged blacks
and prevention and young stroke. in the USA, who have a two- to five-fold higher stroke risk
compared with whites.12 The incidence of stroke in the young
Epidemiology of stroke has been reported to be higher for men than for women older
in young adults than 35 years of age in community-based and population-
There are many published series concerning stroke in young based studies.13,14 On the other hand, one population-based
patients, but the data are conflicting. Comparison between study in Italy reported an increased stroke incidence among
studies is difficult for a number of reasons, including the women under 30 years of age.15
methodology used, age groups, diagnostic criteria, time scale,
and a change in the pathology. The proportion of first-ever Risk factors
stroke in young adults differs from country to country, rang- Modifiable risk factors are the same for both younger and
ing from ,5% to 20% of all strokes.24 older age groups. However, the prevalence of these risk fac-
tors is not the same in these two age groups. Hypertension,
Incidence and proportion heart disease (including atrial fibrillation), and diabetes mel-
In the past 3 decades, a large number of studies have been litus are the most common risk factors among the elderly.6
published on the incidence of stroke in young adults. The In contrast, among 1,008 young stroke patients in Finland,
results of these studies have been rather heterogeneous in the most common vascular risk factors were dyslipidemia
terms of methodology and ethnicity. A systematic review (60%), smoking (44%), and hypertension (39%).7 In another
on the incidence of stroke in young adults was published study, Putaala etal16 investigated the distribution of vascular
by Marini et al, 5 who analyzed 29 studies including risk factors in 3,944 young stroke patients from three distinct
3,589 patients under 45 years of age with first-ever stroke, geographic regions in Europe. The three most frequent risk
published between 1980 and 2009. Crude rates ranged from factors were current smoking (49%), dyslipidemia (46%),
5.76/100,000 to 39.79/100,000 and standardized rates ranged and hypertension (36%).16 Furthermore, among 990 young
from 6.14/100,000 to 48.51/100,000. In the same review, the stroke patients with first-ever ischemic stroke, those without
proportion of ischemic strokes ranged between 21.0% and well documented risk factors had less frequent recurrent
77.9%, intracerebral hemorrhage between 3.7% and 38.5%, ischemic strokes and noncerebrovascular arterial events,
and subarachnoid hemorrhage between 9.6% and 55.4%. as well as lower long-term mortality rates than those with
In a recent study from Bosnia and Herzegovina, ischemic one or more risk factors.17 The investigators concluded that
stroke among young adults was diagnosed in 61% of cases, numbers of risk factors add independent prognostic infor-
intracerebral hemorrhage in 17%, and subarachnoid hemor- mation regarding noncerebrovascular events and mortality
rhage in 22%.6 in young adults.
A few studies on stroke incidence in young adults Classical vascular risk factors, including hyperten-
have been published since 2009. A Finnish study analyzed sion, dyslipidemia, and cigarette smoking have also been
1,008 consecutive ischemic stroke patients aged 1549 years.7 reported to be common in young stroke patients in the

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Table 1 Studies on stroke etiology in young patients collectively account for 20%30% of cases of young stroke.
Reference Country LAA CE SVD ODE UE A wide variety of different and uncommon causes of stroke
Cerrato et al20 Italy 16 24 17 19 24 in young adults is presented in Table 2.
Nedeltchev et al2 Switzerland 4 30 9 24 33 Cervicocephalic arterial dissection is the second most
Rasura et al15 Italy 12 34 3 28 24
Varona et al3 Spain 20 18 5 22 36
common lesion of the cervical arteries after atherosclero-
Jovanovic et al21 Serbia 8 20 22 24 26 sis, and rank first or second with regard to all etiologies of
Putaala et al7 Finland 8 20 14 26 33 ischemic stroke in young adults (up to 25% of cases).23,27
Spengos and Greece 9 13 17 27 34
Moyamoya disease affects mainly Asian people (representing
Vemmos22
Smajlovic et al6 Bosnia and 15 10 26 9 40 6%15% of cases of nonatherosclerotic vasculopathy), but is
Herzegovina described throughout the world. The link between migraine
Tancredi et al23 Italy 9 19 16 29 27 and ischemic stroke has been known for years. The risk is par-
Yesilot Barlas et al24 Europe 9 17 12 22 40
ticularly pronounced among young women having migraine
Note: All numbers are percentages.
Abbreviations: LAA, large artery atherosclerosis; CE, cardiac embolism; SVD, with aura, and is multiplied among smokers and those using
small vessel disease; ODE, other determined etiology; UE, undetermined etiology. oral contraception.28 Inherited coagulation disorders do not
have a significant role in stroke among the young, with the
Peoples Republic of China and New Zealand.18,19 According exception of antiphospholipid antibody syndrome. In one
to the presented results, the prevalence of these risk factors for systematic review, antiphospholipid antibodies, particularly
stroke in young adults is similar around the world. Therefore, lupus anticoagulant, were an independent risk factor for
the earlier thesis that the proportion of stroke risk factors ischemic stroke in young adults in five of six studies.29
depends on geographic, climatic, nutritional, lifestyle, or Rare genetic and hereditary diseases, such as Fabry
genetic diversity, is not entirely correct. disease, cerebral autosomal dominant arteriopathy with
subcortical infarcts and leukoencephalopathy (CADASIL),
Etiology and mitochondrial encephalopathy with lactic acidosis and
The etiology of ischemic stroke in young adults and adoles- stroke-like episodes (MELAS), must be considered in the
cents is diverse and varies according to age and geographic differential diagnosis of young patients with ischemic stroke.
region. In the past 10 years, there have been many published Vasculitides of the central nervous system are complex
series of stroke etiology in young patients, and Table 1 sum- diseases and often reminded when differential diagnosis of
marizes these reports. The TOAST (Trial of Org 10172 in stroke in young adults is discussed. Primary cerebral angiitis
Acute Stroke Treatment) criteria for classification of acute is twice as common in middle-aged men than in women,30 and
ischemic stroke are the most commonly used.25 vasculitis related to infection is more common in developing
Despite a systematic diagnostic approach and more countries and in regions with a higher prevalence of human
accurate diagnostic tools becoming available in the form immunodeficiency virus.31
of vascular imaging and hematologic and genetic studies, Cardioembolic stroke accounts for up to one third of
stroke of undetermined etiology was the most common ischemic strokes in young adults (Table 1). However, it is
etiology among young stroke patients, with the exception often more difficult to diagnose. The causes of cardiogenic
of two studies.2,23 The high number of young stroke patients embolism are different, and 30 years ago Hart developed
with undetermined etiology may be explained in part by the the concept of major and minor sources of cardioembolism
insufficient extent and timing of the investigations. On the (Table3).32 One of the most commonly debated questions is
other hand, the TOAST classification is not perfect, and can the role of patent foramen ovale (PFO) in cardioembolism. The
lead to overestimation of patients with stroke of undetermined prevalence of PFO in the general population is about 20%, and
etiology, mainly because patients with two or more poten- is even higher in young stroke patients (up to 50%). Several
tial etiologies fall into this group. This group also includes studies have confirmed an association between PFO and cryp-
patients with incomplete investigation and those with no togenic stroke, but the finding of a PFO was incidental in one
evident cause despite extensive evaluation. Therefore, a newer third of these patients.33 A recent meta-analysis of PFO closure
classification system for more accurate etiologic subtyping of trials suggests potential but uncertain benefit of PFO closure
ischemic stroke, like A-S-C-O,26 might have an influence on over medical management.34 The limitation of these trials is
reducing the high numbers of strokes being identified as of their small sample size, and the management of cryptogenic
undetermined etiology. Stroke of other determined etiology stroke in young adults with PFO remains unclear.

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Table 2 Uncommon causes of stroke in young adults modifiable risk factors, such as hypertension, cigarette
Nonatherosclerotic Cervicocephalic arterial dissection smoking, and hyperlipidemia.3,6,20 The large studies indicate
angiopathies Cerebral amyloid angiopathy
that hemorrhagic stroke (subarachnoid and intracerebral)
Moyamoya disease
Fibromuscular dysplasia accounts for up to 50% of all strokes that occur under the
Reversible cerebral vasoconstriction syndrome age of 45 years, with reported incidence rates in the range
Susacs syndrome
of 36/100,000/year for subarachnoid hemorrhage and
Sneddons syndrome
Migraine-induced stroke 27/100,000/year for intracerebral hemorrhage.35,36 In general,
Hematologic Hypercoagulable state due to deficiencies of the etiology of intracerebral hemorrhage in young patients is
conditions protein S, protein C, or antithrombin; factor V Leiden
similar to that in those older than 45 years, except for an over-
mutation, prothrombin gene G20210A mutation
Acquired hypercoagulable state (eg, cancer, representation of arteriovenous malformation, cavernoma,
pregnancy, hormonal contraceptive use, exposure drug abuse, and bleeding disorders early in life. Hypertension
to hormonal treatments such as anabolic steroids
remains a frequent cause of intracerebral hemorrhage in both
and erythropoietin, nephrotic syndrome)
Antiphospholipid syndrome younger and older individuals, and the majority of hemor-
Hyperhomocysteinemia rhages are lobar. In young adults with intracerebral hemor-
Sickle cell disease
rhage, the possibility of illicit cocaine or other drug abuse
Myeloproliferative disorders (eg, leukemia,
lymphoma) must be considered. In one study, cocaine and amphetamine
Genetic Fabry disease abuse was associated with an increased rate of hemorrhagic
CADASIL
MELAS
stroke.37 Aneurysms in young adults show the same anatomic
Marfan syndrome locations and clinical findings as in older patients, and suba-
Neurofibromatosis rachnoid hemorrhage before and after the age of 45 years is
Sturge-Weber disease
Inflammatory and Vasculitis (primary angiitis of the CNS, Sjgren diagnosed and managed in the same manner.
infectious syndrome, Wegeners granulomatosis)
Temporal arteritis
Takayasu disease Prevention of strokes
Behets syndrome
Neurosarcoidosis
in young adults
Neurocysticercosis Stroke is the second/third leading cause of death worldwide.
HIV It caused an estimated 5.7 million deaths in 2005, and the
Varicella zoster virus
global number of deaths is projected to rise to 6.5 million in
Neurosyphilis
Tuberculous meningitis 2015 and 7.8 million in 2030.38 Although some studies have
Abbreviations: CADASIL, cerebral autosomal dominant arteriopathy with subcor suggested an increase in the incidence of stroke in young
tical infarcts and leukoencephalopathy; CNS, central nervous system; HIV, human
adults, the prognosis of these patients is generally considered
immunodeficiency virus; MELAS, mitochondrial encephalomyopathy, lactic acidosis,
and stroke-like episodes. to be favorable. However, a recent study by Rutten-Jacobs
et al indicates that the long-term mortality after stroke in
Large-artery atherosclerosis has been shown to be young adults is higher than expected, suggesting a need for
an infrequent cause of ischemic stroke in young adults, further research to improve stroke prevention in this age
accounting for less than 10% of cases. However, the results group.39 Furthermore, stroke in young patients has major
of a couple of studies show a higher incidence of athero- long-term socioeconomic consequences. In one study, it
sclerotic stroke, mainly due to the presence of multiple was estimated that the average cost of a hospital stay for a
young stroke patient was US$34,886 for ischemic stroke,
Table 3 Cardiac sources of embolism US$146,307 for subarachnoid hemorrhage, and US$94,482
Major risk sources Minor risk sources for intracerebral hemorrhage.40
Atrial fibrillation Patent foramen ovale Prevention is the primary treatment strategy aimed at
Prosthetic heart valves Atrial septal aneurysm, recent reducing the morbidity and mortality related to stroke, and
Myocardial infarction Spontaneous echo contrast
adequate treatment, control of risk factors, and lifestyle
Intracardiac thrombus Mitral valve prolapse
Mitral stenosis Mitral annular calcification changes can prevent up to 50% of strokes. A number of
Atrial myxoma Calcific aortic stenosis recommendations on the management and prevention of
Dilated cardiomyopathy (EF ,35%) Ventricular akinesia (EF .35%)
Left ventricular aneurysm
stroke and transient ischemic attack have been published. The
Infective endocarditis guidelines of the European Stroke Organization (published in
Abbreviation: EF, ejection fraction. 2008 and updated in 2009)41 and the very recent guidelines

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for the primary prevention of stroke from the American Heart The prevalence of current smoking in developed countries
Association/American Stroke Association42 cover stroke is decreasing, but in developing countries is still high.
prevention in detail. However, there are no specific recom- Therefore, smoking cessation programs need to be more
mendations or guidelines for primary or secondary stroke widespread and effective in developing countries. Smoking
prevention in young adults. In general, prevention strategies cessation programs and changes in legislation to reduce the
are similar for younger and older patients. opportunities to smoke need to be a priority for policymak-
ers to save millions of lives and reduce smoking-related
Primary stroke prevention morbidity.48 Two meta-analyses indicate that a diet rich in fruit
Primary prevention aims to reduce the risk of stroke in and vegetables and with a reduced salt content can reduce the
asymptomatic subjects. It is focused on identifying and man- risk of stroke.49,50 The effect of physical activity and exercise
aging known vascular risk factors, such as arterial hyperten- on health and disease has been the focus of much research
sion, disorders of lipid metabolism, and diabetes mellitus, and attention. A meta-analysis of 23 studies concluded that there
non-drug strategies and lifestyle changes, including quitting was strong evidence that moderate and high levels of physical
smoking, limiting alcohol consumption, reducing elevated activity were associated with a reduced risk of total, ischemic,
body weight, increasing regular aerobic physical activity, and hemorrhagic stroke.51 The mechanism by which exercise
and adopting a healthy diet with more fruit and vegetables decreases stroke risk is likely to be multifactorial and to
and less salt.43 include blood pressure, lipid, and weight control.
Hypertension is the risk factor that most significantly
correlates with stroke and plays a role in more than 50% of Secondary stroke prevention
episodes of stroke worldwide. High blood pressure can lead It has been shown that 3%4% of all patients who expe-
to occlusive stroke, as well as intracerebral or subarachnoid rience a stroke will experience a second stroke. The
hemorrhage, and correlates with the risk of first-ever stroke cumulative 5-year recurrence rate among young adults
and recurrent stroke. A summary of the recent clinical trial was 9.4% for nonfatal or fatal ischemic stroke, and these
data confirms that antihypertensive therapy substantially individuals, despite their young age, were at increased risk
reduces the risk of any type of stroke, as well as stroke-related of recurrent arterial events, predicted by mostly modifiable
death and disability.44 Treatment should be individualized and baseline risk factors.52 In a very recent study, Aarnio etal
target blood pressure is ,140/90 mmHg. The risk of stroke analyzed long-term mortality in 970 consecutive young
is two to six times higher in diabetic patients; however, dia- and middle-aged stroke patients.53 The observed mortality
betes mellitus is not a common risk factor in young adults. was seven-fold higher than the expected mortality, and was
Glycemic control reduces microvascular complications, but particularly high among patients who experienced a recur-
there is no evidence that improved glycemic control reduces rent stroke. The authors concluded that there is a need for
the incidence of stroke in patients with diabetes mellitus. more robust primary and secondary prevention of stroke
In younger diabetics, treatment should be targeted toward in young adults.
control of blood pressure (,130/80 mmHg) and treatment of For secondary stroke prevention, aimed at reducing the
hyperlipidemia, especially in individuals with additional risk risk of another stroke, identification of the etiologic mecha-
factors. Blood lipid abnormalities are another risk factor that nism of the initial stroke and the presence of any additional
should be corrected as part of primary prevention in terms risk factors is most important. It consists of optimal treatment
of overall cardiovascular risk. Therapeutic lifestyle changes of vascular risk factors (arterial hypertension, hyperlipi-
should be the first strategy. Treatment with statins is recom- demia, diabetes mellitus, and cardiac disease), administer-
mended in patients estimated to have a high 10-year risk for ing antiplatelet or anticoagulant therapy, and if indicated,
cardiovascular events.45 Epidemiologic data indicate a strong invasive surgical or endovascular therapeutic procedures.
relationship between cigarette smoking and ischemic stroke An integral part of this is lifestyle changes, emphasizing
and subarachnoid hemorrhage, particularly in the young age regular physical activity, a diet low in salt and saturated fat
group.46,47 Cigarette smoking also has a synergistic effect via and high in fruit and vegetables, reducing overweight, and
its link with other vascular risk factors, such as hypertension, quitting smoking and heavy use of alcohol.41 Adequate long-
diabetes mellitus, use of oral contraceptives, and physical term secondary prevention was associated with a reduced
inactivity. Stopping smoking mitigates the risk of stroke, risk of death and recurrent stroke and improved outcome in
as it does with other conditions such as coronary disease, routine settings.54,55 Hypertension is the single most impor-
peripheral vascular disease, and death from vascular causes. tant vascular risk factor for stroke. In practice, young adults

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who have had a stroke should have tight control of blood appropriate treatment with warfarin.61,62 Although a detailed
pressure to #130/80 mmHg, with the clinicians choice review of the prevention of stroke in patients with specific
of antihypertensive regimen. Especially for these young etiologies is outside the scope of this article, a few common
stroke patients, evaluation for the etiology of uncontrollable conditions can be mentioned. For lack of results from clinical
hypertension such as renal artery stenosis, pheochromo- trials on stroke prevention in patients with PFO, antiplatelet
cytoma, hyperaldosteronism, or systemic vasculitis may treatment is considered appropriate for stroke patients with
be indicated in some cases. The benefit of statins in young isolated PFO and percutaneous closure of PFO is not recom-
stroke patients with predominantly nonatherosclerotic stroke mended.63 In stroke patients with cervicocephalic arterial dis-
etiologies remains controversial; however, in young patients section, anticoagulation is not recommended over antiplatelet
with cryptogenic stroke, statin therapy was associated with therapy.64 Patients with ischemic stroke of unclear etiology
fewer recurrent vascular events.56 It is well established that and under 45 years of age must be tested for thrombophilia.
diabetes mellitus is an independent risk factor for stroke, Anticoagulant therapy is normally indicated in the event of
while data on stroke recurrence are more sparse. Diabetic a proven deficiency of antithrombin III, protein C, or pro-
stroke patients, both young adults and the elderly, have higher tein S, as well as resistance to activated protein C (factor V
mortality, a less favorable outcome, more severe disability, Leiden). ASA may be considered as a preventive treatment in
and slower recovery after a stroke, as well as higher rates of patients with antiphospholipid antibody positivity after a first
stroke recurrence within 6 months.5759 These patients also ischemic stroke. Oral anticoagulants for an INR of 23 are
have a high prevalence of other comorbid risk factors, such as recommended for patients who meet the criteria for antiphos-
hypertension, hyperlipidemia, obesity, and insulin resistance, pholipid syndrome.65 Migraine with aura is associated with
to elevate their risk of stroke. Therefore, more aggressive a six to eight-fold increased risk of stroke in patients under
treatment of these comorbidities is required. the age of 45 years, but future stroke occurrence remains
In stroke patients with defined large-artery atherosclero- unclear. There is no definite guideline for use of antiplatelet/
sis or small-vessel disease, risk factors should be modified antithrombotic therapy in stroke prevention for women with
and antiplatelet drugs are recommended, along with carotid a history of pregnancy-related stroke. Pregnant women with
endarterectomy or percutaneous transluminal angioplasty in stroke or transient ischemic attack may be considered for
selected patients. According to the guidelines, acetylsalicylic treatment with unfractionated or low molecular weight heparin
acid (ASA) should be a first-choice antiplatelet drug in sec- throughout the first trimester, followed by low-dose ASA for
ondary prevention.41 First-choice treatment can be ASA in the remainder of the pregnancy, if a high-risk thromboembolic
combination with dipyridamole (25/200 mg twice daily) or condition is ruled out.65 In ischemic stroke of undetermined
clopidogrel monotherapy (75 mg/day). The combination of origin, antiplatelet drugs are recommended as the first-line
ASA + clopidogrel is not recommended in secondary stroke treatment, and anticoagulants can be used when strokes
prevention except in the case of the coincidence of stroke recur despite treatment with antiplatelet drugs. One of the
and a recent myocardial infarction or status post-coronary main problems in secondary stroke prevention is long-term
stenting. Clopidogrel 75 mg/day is considered a first-choice use of secondary prevention medications following stroke,
treatment, especially in patients with ASA intolerance. In because up to one third of stroke patients discontinued one or
patients with cardioembolic stroke due to atrial fibrillation more such medications within 1 year of hospital discharge.66
or other cardioembolism, warfarin (International Normalized Leistner etal compared the quality of secondary prevention
Ratio [INR] 23) is indicated for secondary prevention. For consisting of usual care versus a stepwise modeled support
patients unable to take oral anticoagulants and those who program (outpatient appointments with a combination of
refuse all forms of anticoagulation, ASA + clopidogrel educational and behavioral strategies)67 and found that con-
combination therapy, or less effectively only ASA is recom- trol of risk factors remains unsatisfactory in usual care and a
mended.60,61 Novel oral anticoagulants (NOAC; thrombin and support program leads to major improvement of secondary
factor X inhibitors) have the added benefit of not requiring prevention.
INR monitoring. Clinical studies have demonstrated noninfe-
riority of all NOAC tested in comparison with warfarin, with Conclusion
better safety and a reduced risk of intracerebral hemorrhage. Stroke in young adults is a major public health problem, and
NOAC can be also used for secondary prevention of cardi- further research using standardized methodology is needed.
oembolic stroke in patients with stroke recurrence despite Future studies should be multicenter in design, with a specific

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definition of the term young adults and specific diagnostic 14. Vibo R, Krv J, Roose M. The third stroke registry in Tartu, Estonia:
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The author reports no conflicts of interest in this work. ever ischemic stroke in young adults aged 15 to 45 the Athens Young
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